➢ Sport-related concussion treatment includes three major phases: initial evaluation at the time of the injury, treatment while the patient is symptomatic, and evaluation of the readiness for a gradual return to participation.
➢ Each concussion evaluation should include similar elements: assessment of symptoms, assessment of cognitive ability, assessment of coordination (of the eyes, upper extremities, and lower extremities), and assessment for additional injuries.
➢ The spine-boarding recommendations from the American College of Emergency Physicians, National Association of EMS Physicians, and National Athletic Trainers’ Association have changed. These recommendations include both decreased use of spinal immobilization and removal of the helmet and shoulder pads prior to securing the athlete to the board when sufficient numbers of trained providers are present.
➢ Preseason training and pregame meetings or “medical time outs” should become standard practice for the sidelines medical team (including the athletic trainer, team physician, emergency response personnel, and possibly others).
During a goal-line stand, a sixteen-year old linebacker attempts to tackle the fullback. He does not get up once the play stops. As the athletic trainer runs onto the field, she observes a young man lying supine. On initial contact, she determines that he is unresponsive to verbal commands but is breathing and has a strong pulse. Over the next thirty seconds, the student-athlete gradually awakens but expresses confusion and an inability to recall the play or recent events in the game. He complains of ringing in the ears and a headache. He denies neck pain, numbness, or tingling in the arms or legs. Physical examination reveals grossly intact sensation and motor strength in the upper and lower extremities. There is some cervical paraspinal tenderness but no midline tenderness or step-offs. While a brief examination reveals that neurological function is grossly intact, ocular examination reveals horizontal nystagmus and jerky pursuits. There were no other positive findings.
Current State of Literature Relating to Spine Boarding, Equipment Removal, and Concussion Diagnosis and Care
Scenarios such as the one described above will occur throughout the United States during the football season, raising the possibility of closed head injuries such as intracranial bleeds, spinal cord injuries, and concussions. A concussion is defined as a subset of mild traumatic brain injury that is generally self-limited. It is a traumatically induced transient disturbance of brain function and involves a complex pathophysiological process1 (Table I). Sport-related concussion (SRC) is primarily a metabolic disturbance and not a structural injury such as an intracranial bleed2. Current data indicate that as many as 3.8 million SRCs occur annually3-5. Recent high school data have shown a fourfold increase in reported SRCs over an eleven-year period (from 1997 to 2008)4. It is not known if this increase is due to an increase in prevalence or to heightened public awareness and improved detection3,6. The trend of concussion treatment has changed from returning concussed athletes to play during the same game to more conservative approaches involving prolonged physical and cognitive rest1,7-10. The current understanding and treatment of SRC began in 2001 with the first International Conference on Concussion in Sport11. Since its initial meeting, the Concussion in Sport Group (CISG) has convened in 2004, 2008, and, most recently, 20122,12,13. In addition to the CISG meetings, the American Academy of Neurology (AAN), American Orthopaedic Society for Sports Medicine (AOSSM), and National Athletic Trainers’ Association (NATA) have revised their position statements regarding the prevention and treatment of SRCs in student athletes1,8,14. Every state in the country now has a youth concussion law. Generally, these laws mandate the immediate removal from play of any student-athlete with a suspected concussion so that he or she can be carefully evaluated. If the student-athlete is then diagnosed with a concussion, he or she may not return to play the same day, is typically required to undergo clearance by a health-care provider, and then gradually returns to physical activity.
Spine-related injuries can occur independently from or in addition to an SRC. Concussed student-athletes should be managed with a high index of suspicion for potential spine-related injuries when being evaluated by the treating clinicians, including athletic trainers, team physicians, and emergency physicians. The rate of catastrophic cervical spine injuries has declined over the last thirty years6,15-18. When injuries to the spine do occur, they can be devastating. Axial loading is the primary mechanism causing severe injuries to the spinal cord19,20. Traditional care includes transporting the potentially spine-injured athlete by mechanically stabilizing the head and spine with the application of a cervical collar and strapping the patient onto a long rigid board (spine board). NATA recently revised21 its 1998 Inter-Association Task Force for Appropriate Care of the Spine-Injured Athlete document and its 2009 Position Statement22 into an executive summary: “Appropriate Care of the Cervical Spine Injured Athlete”23. These changes will potentially impact the physician on the sidelines and in the emergency department.
Initial Care on the Field
An athletic trainer typically serves as the first responder for most on-field injuries. The athletic trainer performs a primary survey and secondary survey and recruits assistance as needed (Table II). On initiating contact with a student-athlete with a possible spine injury, the athletic trainer should provide manual immobilization of the head and neck while conducting the evaluation. The primary survey includes an assessment of the airway, breathing, circulation, need for cardiac defibrillation, and potential for neurological disability, and it also involves the removal of equipment if warranted. The primary survey establishes the initial stability of the patient and the necessity of transporting the patient for advanced care23-26. The neurological assessment of the primary survey involves both an evaluation of the overall level of consciousness (alert, responsive to verbal stimuli, responsive to painful stimuli, or unresponsive) and a sensory/motor assessment of the exposed extremities26,27.
Determining when to use a spine board can be difficult. Historically, Emergency Medical Service (EMS) providers were trained that any patient with a traumatic injury to the head and/or neck or any patient with traumatic neck or back pain should be fully immobilized with a rigid cervical collar and a long spine board prior to transport28. Recently revised EMS guidelines now recommend spinal motion restriction, which, in the case of a minor injury, may only require a cervical collar and having the patient recline semirecumbent on the EMS stretcher. These guidelines have been revised because true spinal immobilization is impossible and partly because there is a lack of evidence supporting the use of rigid spine boards in many trauma patients23,29,30. In many areas, new EMS protocols will decrease the use of long spine boards for many patients. Recent recommendations from NATA and the American College of Emergency Physicians (ACEP) help to clarify when spinal board immobilization is recommended as a part of spinal motion restriction. Spinal board immobilization should be applied to an injured student-athlete with spinal pain or tenderness, focal neurological complaints or deficits, or blunt trauma with an altered level of consciousness23-25 (Table III). If, based on the recent NATA and ACEP recommendations, the on-the-field medical team believes that spine boarding is appropriate, all providers should be prepared to collaborate in the process.
Once the decision has been made to use a spine board, the sports-medicine team should also decide if athletic equipment removal is appropriate prior to transport31,32. The revised NATA Executive Summary now supports that protective equipment may be removed prior to transport to an emergency facility23. This approach emphasizes the importance of access to the airway and chest, which is critical when a student-athlete’s condition may rapidly decompensate. It also ensures that the providers who are most familiar with the athletic equipment, the sports-medicine team, are participating in its removal33-35. Athletic equipment is designed to maintain a neutral alignment of the spine when both a well-fitting helmet and appropriate shoulder pads are worn. If either the helmet or the shoulder pads are removed, then both should be removed to avoid excessive flexion or extension of the cervical spine. Key steps in equipment removal start with a health-care provider above the head offering cervical and head stabilization. Then a second rescuer cuts away the front of the jersey and the front of the shoulder pads. The second rescuer straddles the patient and assumes head/neck/torso stabilization while two other providers slide off the helmet and shoulder pads (Table IV). The NATA Executive Summary recommends a minimum of three appropriately trained health-care providers who are well versed in equipment removal to be present for equipment removal. This can be a prohibitive factor with high school game coverage. Therefore, the sports-medicine team may decide to keep both the helmet and the shoulder pads in place while only removing the facemask prior to placing the student-athlete on the spine board and arranging for transport for advanced care23,31,32.
With any suspected injury to the head or neck, health-care providers should also conduct a thorough concussion evaluation36-39 (Table V). This evaluation begins during the primary and secondary surveys. Loss of consciousness and posttraumatic amnesia, while associated with an SRC, only occur in approximately 10% and 20% of cases, respectively40. Commonly reported symptoms are divided into four clusters: somatic (headache, nausea, phonophobia/photophobia, and balance disturbances), cognitive (confusion, memory loss, difficulty concentrating, slowed processing speed, and feeling “in a fog”), behavioral (irritability, anxiety, sadness, emotional lability), and sleep (drowsiness, fatigue, and altered sleep cycles)41,42. Self-reported symptoms are a valuable component of the SRC assessment but are not always reliable43. Clinicians must remain vigilant for underreporting and delayed onset of symptoms44,45. The sidelines evaluation of concussions should therefore include functional testing of cognition and coordination13. Physical examination findings consistent with an SRC include alterations to coordination in the eyes, upper extremities, and lower extremities. For the eye examination, these findings includes end-position nystagmus, jerky pursuits during full eye range of motion, and saccadic dysmetria (overshooting or undershooting a visual target)46-48. Upper-extremity abnormalities may include deficits in rapid alternating hand movements or finger-to-nose testing. The lower-extremity coordination deficits have been formalized into a validated Balance Error Scoring System (BESS) in which the student-athlete is asked to assume three stances, each for twenty seconds, and the total number of unstable errors is noted49. Evidence-based cognitive assessment measures include the SAC (Standardized Assessment of Concussion) and SCAT3 (Sport Concussion Assessment Tool, 3rd edition)13,50. A relatively new sidelines measure of SRC is the King-Devick (K-D) test. The K-D test purports to measure impaired eye movements (saccades), which are indicative of suboptimal brain function51. Preliminary evidence regarding the sensitivity (90% to 100%) and specificity (92% to 97%) of the K-D test is promising but has been primarily based on relatively small sample sizes of patients with observed and unobserved injuries52-56. With all of these functional assessments, preseason (baseline) testing is important to detect meaningful clinical changes following a suspected concussion.
An inherent part of the concussion/spine evaluation includes looking for signs of a closed head injury (e.g., fracture, intracranial bleed, increasing intracranial pressure). These clinical findings may not be present at the time of the initial evaluation. Therefore, the concussed student-athlete should be monitored at frequent intervals for the remainder of the game to ensure that the symptoms are not progressive (e.g., worsening headache, seizure, deteriorating level of consciousness, repeated vomiting, focal neurological signs), which would necessitate transport to the emergency department for further evaluation1,13,32,47.
The majority of SRCs do not warrant transport to the emergency department. In these cases, education of the student-athlete and a responsible third party (parent, guardian, or roommate) is imperative to assist in the monitoring for worsening symptoms8. The involved student-athlete and his or her caregiver(s) should be provided with pertinent information regarding the injury, a list of symptoms, and indicated and contraindicated activities8,57. It should be clear that no physical exertion, training, or competition should be undertaken until after a follow-up examination by an appropriate health-care practitioner as defined by each state. The NATA as well as the CISG have created home instruction sheets appropriate for student-athletes and their caregiver(s)8,13.
Transfer of Care from the Field by EMS Providers
The sports-medicine team will determine the necessity for urgent transport by EMS providers for advanced care. Depending on the level of competition, the EMS providers may be on site already or may have to be summoned. On arrival of the EMS providers, the athletic trainer or physician should provide a brief report of all pertinent information, including the time of injury, presumed mechanism of injury, initial presenting signs and symptoms, any changes (improvement or decompensation), and any interventions or treatments that have been rendered thus far. EMS providers will then perform another primary and secondary survey, paying particular attention to the likelihood of concussion, cervical spine injury, and other traumatic issues. The EMS providers will continue to monitor the student-athlete for signs of increased intracranial pressure with frequent neurological checks31.
Together with the athletic trainers and team physician, EMS providers should consider local protocols and resources in determining transport destination, whether to the closest emergency department or to the regional trauma center. This hospital destination consideration should involve the availability of advanced imaging (computed tomography [CT] and/or magnetic resonance imaging [MRI]) as well as specialty consultation for intracranial, spinal, and other traumatic injuries. If possible, the athletic trainer or team physician can communicate with the receiving emergency department, although caution is advised as multiple phone calls being placed to the same facility may have a negative impact on the overall emergency department functioning and patient care.
Advanced Care in the Emergency Department
Having received advanced notification, the emergency department team should make appropriate preparations for the patient’s arrival. If protective athletic equipment was not removed prior to transport, it should be removed in the emergency department in a manner that follows the steps outlined above (Table IV). These steps should be directed in an appropriate and deliberate manner by the provider who is most experienced in the process of equipment removal. If spinal injury is strongly suspected, initial imaging should occur prior to removal of equipment as most sports equipment is radiolucent. A long spine board, if used for transport, should be removed while maintaining in-line stabilization of the spine. If spinal injury is suspected, a slider board may be used to minimize spinal motion during further transfers. When the long board and sports equipment are removed, a rigid cervical collar should be placed (if not already applied by EMS providers) and should remain in place until the cervical spine is cleared either clinically or radiographically.
During the initial evaluation, the emergency physician should consider spinal, head, and other traumatic injuries58,59. There are several rules systems that may help the clinician to decide whether spinal imaging is required for lower-risk patients. The most widely used are the National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-Spine Rule (CCR)60 (Table VI). Imaging is recommended for patients with altered mental status, midline spinal tenderness, or neurological deficits. Of these, the CCR appears to be superior with respect to both sensitivity and specificity for cervical spine injury and with respect to reducing unnecessary radiography61. However, if all criteria cannot be met, imaging should be performed, starting with lateral cervical spine radiographs that include the C7-T1 level. After these initial images, anteroposterior and open-mouth odontoid radiographs can be made. Flexion-extension radiographs should not be made in the acute setting for any patient with highly suspicious neck pain, distracting injuries, or palpable step-offs. For these patients, many centers have moved to standard CT scans of the cervical spine for initial radiographic evaluation. MRI is becoming more available and may be useful in cases in which there is a high index of suspicion for injury of the spinal cord, canal, and ligamentous structures. MRI can also be used to more fully characterize abnormalities seen on radiographs or CT scans. If neurological deficits exist or marked midline pain and/or tenderness persist despite a negative radiographic evaluation, MRI should be considered. If neurological abnormalities are noted on examination or important abnormalities are seen on spine imaging, then a spine surgeon should be consulted. In the rare case in which the spine cannot be completely cleared clinically or radiographically in the emergency department and a spine surgeon is not available, the patient may remain in a rigid cervical collar for seven to fourteen days before returning for outpatient spine surgery.
The emergency physician should be suspicious of an SRC when any student-athlete presents with a head or neck injury. The emergency department evaluation of an SRC is similar to the sidelines evaluation (Table V). A review of the common symptom cluster (cognitive, physical, emotional, sleep) is reviewed. Likewise, the physician performs a physical examination to look for the common abnormalities associated with a concussion (coordination deficits of the eyes, upper extremities, and lower extremities). This evaluation should also include a cognitive component with a validated tool (e.g., SAC, SCAT3, K-D). Baseline values may not be available to the emergency physician, so he or she should use his or her clinical judgment when interpreting the results.
Intracranial injuries should also be considered, and a number of clinical decision guidelines have been developed to guide the emergency physician in the evaluation of the patient. The most widely used decision rules include the Canadian CT Head Rule, the New Orleans Criteria, and, for pediatric patients, the Pediatric Emergency Care Applied Research Network (PECARN) criteria60-62 (Table VII). The patient should be monitored for signs and symptoms of increased intracranial pressure, and any changes in neurological status should prompt rapid reevaluation and should lower the threshold for diagnostic imaging.
In applying the decision rules for brain imaging, it is important to recall that standard imaging modalities are meant to evaluate for structural injuries in the brain, such as skull fracture, subdural or epidural hematoma, intraparenchymal hemorrhage, or cerebral edema. By definition, a concussion is a metabolic/physiological injury. An isolated SRC is not associated with identifiable abnormalities on standard neuroimaging63. These head CT rules are not intended to exclude head injury in situations in which persistent headache, nausea, vomiting, and amnesia may represent more serious intracranial injury. Thus, reliance on these rules for patients with more than minor injuries or patients with persistent or worsening symptoms is strongly discouraged.
Patients with a normal examination, nonconcerning and stable symptoms, and normal findings on neuroimaging studies (if indicated) may be discharged from the emergency department to a companion with appropriate discharge instructions similar to the sidelines management noted above13,64. Emergency physicians must recall that concussion symptoms may wax and wane in the hours and days following an injury. It is crucial that if the diagnosis of concussion has been applied either on the sidelines or in the emergency department, then the student-athlete and/or parents should be given anticipatory guidance regarding expected symptoms, follow-up instructions, and criteria for return to the emergency department13,65.
According to the revised guidelines, spinal motion restriction should continue until a thorough examination, and, if necessary, imaging, are performed. When symptoms persist or if concussive symptoms preclude a full examination, spine precautions should be maintained. In cases in which the cervical collar has been maintained, outpatient reassessment by a spine surgeon at seven to fourteen days is warranted. At that time, repeat history and examination should be performed. If all symptoms have resolved and there are no neurological complaints, then the cervical collar can be removed under supervision and a complete examination can be performed. Flexion-extension radiographs may be made at this time as deemed necessary by the spine surgeon. For student-athletes with persistent signs or symptoms, advanced imaging may be considered at this time.
The initial treatment of a concussion involves relative rest10,13,14,66, including both cognitive rest (limiting homework, television, computers, and video games) and physical rest (avoiding activities that raise the heart rate). The Zurich guidelines have been instrumental in providing a structured mechanism of rest followed by a gradual reintroduction of physical activity and return to play13. As symptoms subside, cognitive activities are the first to be gradually resumed. Student-athletes should consider returning to some of their classes when they are able to tolerate thirty to forty-five minutes of cognitive stimulation17. Academic accommodations may aid this gradual return to school. These accommodations might include taking school work home, having half-days at school, and having extra time to take tests and quizzes. Other modifications may be required, depending on the student-athlete’s specific symptoms, such as the use of sunglasses for photosensitivity or the use of a hall pass to change classes early in order to minimize exposure to noisy and crowded hallways for student-athletes with vestibular symptoms.
Sport-related training or participation should not be attempted until the student-athlete is evaluated and cleared by the appropriate licensed health-care professional. This follow-up examination includes similar elements as the sidelines assessment: a neurological examination, musculoskeletal examination, and concussion-focused examination. The symptoms should be back to baseline levels. The neurological functioning should be objectively evaluated with standardized tools such as the SCAT3, K-D test, or computer-based neurocognitive test13,47,67. Clinicians will need to use a multidimensional approach to determine the status of the student-athlete. There is no one test that can stand alone as the determinant. Returning to participation should include a several-day progression that introduces physical exertion first, followed by advancement to coordination and finally to sport-specific skills13,14 (Table VIII). Standard medical practice for this graded progression is that only one stage should be attempted per day.
The majority of SRCs last less than two weeks41,68,69. If a student-athlete is still very symptomatic at three weeks, consideration should be given to the possibility of a protracted or complicated recovery, and referral for advanced care should be considered70,71. Individuals with a prolonged course may have symptoms that require treatment and not just continued cognitive and physical rest72. Preexisting psychological factors, especially anxiety and/or depression, are major predictors for a protracted recovery73-75. Referring student-athletes for neuropsychological evaluation at this point provides critical clinical information about cognitive recovery and psychological functioning. This information can be used to inform return-to-learn compensatory strategies and to evaluate whether the cognitive concerns are actually due to attention disruption, slowed processing speed, and/or psychological distress. Other referrals may be appropriate depending on symptom patterns72. For patients with persistent dizziness and vestibular difficulties, physical therapy may be helpful76. For others with eye-tracking difficulties or accommodation deficits, occupational therapy may be appropriate49. In protracted cases, there may be a role for a controlled assessment of exercise tolerance (with the Buffalo Concussion Treadmill Test) to determine a subthreshold activity level from which to initiate therapeutic exercises77,78.
The care of a concussed and possibly spine-injured student-athlete has changed over the last several years. These changes in care have coincided with new research, revised protocols, and a greater community awareness of these injuries12,23. The team physician is one member of the sports-medicine team. There are several opportunities to collaborate as the team provides optimal care. This collaboration begins before the competition or event79-85. The 2015 NATA statement recommends a pregame medical time-out to discuss emergency protocols and procedures between the athletic trainers, team physicians, and EMS providers. It allows all potential caregivers to understand protocols and procedures and each person’s specific duties during an emergency response. It also determines communication techniques between the sideline care teams. There may not be enough providers routinely on the sidelines at high school games, and a response team will need to be created from the available providers. If possible, the sports-medicine team should also train annually prior to the start of team practices.
This collaboration continues as the care transitions from the sidelines to the EMS and emergency department providers. Clinical information must be relayed effectively and quickly to each member in the chain. This information may be relayed verbally to the EMS responder and by means of a written note or telephone call to the receiving emergency department. This communication is especially important when multiple diagnoses have been made on the sidelines (e.g., concussion, facial injury, and/or spinal injury).
Concussion symptoms can ebb and flow day by day13,47. Once an appropriate health-care provider (e.g., an athletic trainer or emergency physician) has made the initial diagnosis, subsequent providers should focus on the clinical treatment of any remaining symptoms rather than attempt to retrospectively evaluate the initial diagnosis. The majority of SRCs do not warrant transport to the emergency department or neuroimaging and can be treated on the sidelines by either the athletic trainer or team physician. If the student-athlete is taken to the emergency department, the concussion evaluation is a continuation of the initial sidelines assessment, with the evaluation of signs and symptoms, neurological function, cognitive function, and additional structural injuries. Effective disposition from the sidelines or emergency department should include a handout on concussion care. This handout should be reviewed with a family member or guardian. Emphasis should also be made that clearance from the concussion will require follow-up evaluation and cannot be reliably predicted at the time of the injury.
Care of the symptomatic student-athlete is improved when the physician, athletic trainer, family, and school representatives all work closely together. A comprehensive concussion-treatment program should include a communication mechanism so that the athletic trainer can inform teachers of the need for academic adjustments and accommodations for the recovering student-athlete17,86,87. If symptoms emerge with reintegration into the classroom, the student-athlete may be taking on too many academic demands too quickly, and this information should be related back to the medical staff. This same level of communication is valuable if there are any recurrent symptoms once the student-athlete is cleared and allowed to initiate his or her return-to-play progression. The most important aspect of managing student-athletes who have concussions is individualized care based on each patient’s unique symptoms and recovery curve.
Additional resources can be found online at the Centers for Disease Control and Prevention’s “Heads Up” portal: (http://www.cdc.gov/headsup/providers/index.html). This portal includes a physician training course, sideline assessment tool, emergency department and office-based evaluation forms, discharge instruction sheets, and return-to-play progression guidelines.
After the initial evaluation, the athletic trainer determined that the student-athlete had symptoms suggestive of a concussion. Further examination demonstrated grossly intact cranial nerves; however, the findings of horizontal nystagmus and jerky pursuits on eye examination supported a probable SRC. Given the patient’s loss of consciousness, degree of confusion, and neck tenderness, the athletic trainer decided that spinal motion restriction was indicated. The athletic trainer, team physician, and EMS crew worked together to remove the patient’s helmet and shoulder pads, applied a cervical collar, and secured the patient to a long spine board. EMS providers transported the patient to the local emergency department. The athletic trainer called ahead to notify the receiving emergency department of the clinical situation (a likely concussion and precautionary spinal motion restriction) and notified the coaches, parents, and school administrators of the situation. The emergency physician evaluated the patient and determined that a CT scan of the head was not indicated because the symptoms were decreasing. Radiographs of the cervical spine revealed normal findings, and an examination revealed that the neck was nontender and normal, so the collar was removed. The emergency physician performed a SAC test, eye examination, and BESS test. The student-athlete performed poorly on these items, confirming the diagnosis of an SRC. The emergency physician provided the family with a concussion care sheet and recommended that the patient should participate in no practices or training until a follow-up outpatient visit. The athletic trainer assessed the student-athlete daily and coordinated accommodations between the community physician and the school administration. Once the student-athlete’s symptoms had resolved and his performance on neurocognitive testing had returned to baseline, his treating clinician (athletic trainer or team physician) cleared him to gradually return to participation following the school’s protocol. He was able to successfully participate in a game three weeks after the injury and completed the season without any subsequent issues.
Investigation performed at James Madison University, Harrisonburg, VA
Disclosure: No external funds were received in support of this study. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author (or the author’s institution) had a relevant financial relationship in the biomedical arena outside the submitted work.
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